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INTRODUCTION: Fear-avoidance beliefs (FAB) play a crucial role in the treatment outcomes of post-surgery patients. These beliefs can lead to activity avoidance, increased pain, and decreased quality of life. Therefore, accurately measuring these beliefs in Iranian patients is of significant importance. The Fear-Avoidance Belief Questionnaire (FABQ) is a patient-reported questionnaire that evaluates individuals FAB. Since the validity and reliability of the Persian version of FABQ (FABQ-P) have not been assessed based on the Iranian population and sociocultural contexts, the current study has been implemented to determine the reliability and validity of the FABQ-P among Iranian post-operative patients by translation and psychometric properties. METHODS: This methodological study conducted in 2023, a sample of 400 patients who had undergone surgery were selected using a convenience sampling method. The scale used in the study was translated and its psychometric properties were evaluated through network analysis and assessments of construct validity (including exploratory and confirmatory factor analysis), convergent validity, and discriminant validity. Additionally, the study assessed the internal consistency of the scale. RESULTS: The MLEFA results with Promax and Kaiser Normalization rotation yielded two factors explaining 57.91% of the variance, encompassing 13 items. Also, the model was approved by CFA. Convergent and discriminant validity have been confirmed through the following criteria: Average Variance Extracted (AVE) exceeding 0.5, Composite Reliability (CR) surpassing 0.7, and Heterotrait-Monotrait Ratio of Correlations (HTMT) equating to 0.597. As for reliability, Cronbachs alpha, composite reliability (CR), and MaxR for all constructs were greater than 0.7, demonstrating good internal consistency. CONCLUSION: As demonstrated by the results, the FABQ-P has a satisfactory level of reliability along with authentic validity according to the sociocultural contexts of Iranian post-operative patients.

• Kinesiophobia correlates moderately with disability in knee osteoarthritis (OA) patients (r = 0.516). • Fair correlations were found between kinesiophobia and pain (r = 0.362) and functional limitation (r = 0.270) in knee OA. • Comprehensive meta-analysis reveals significant associations between kinesiophobia and knee OA symptoms. • Despite high heterogeneity, the certain of evidence is low to moderate. Knee osteoarthritis (KOA) is a prevalent degenerative joint disease associated with pain, disability, and functional limitations. Kinesiophobia, the fear of movement, has been linked to disability and pain in KOA patients. This study aimed to analyze the relationship between kinesiophobia and symptoms of KOA. A comprehensive literature search was conducted in four electronic databases (PubMed/Medline, Web of Science, Scopus and Science Direct) with the following inclusion criteria: 1) recruited participants with diagnostic of knee osteoarthritis; 2) measures of pain, disability and/or functional limitation through questionnaires or physical tests; 3) articles exploring the correlation between kinesiophobia, and pain, disability, and/or functional limitation as principal or secondary outcome; 4) primary data studies (observational and experimental). A total of 17 studies involving 1,574 participants (mean age 61.04 ± 5.79 years) were included in the corresponding meta-analyses. Results showed a moderate correlation between kinesiophobia and disability (r = 0.519; p-value=0.004), and fair correlations of kinesiophobia with pain (r = 0.362; p-value<0.001), and functional limitation (r = 0.270; p-value<0.001). Despite high heterogeneity (I2: 89.4% for pain, 94.6% for disability, and 90.4% for functional limitation), 52% of studies displayed low risk of bias. In conclusion, kinesiophobia positively correlates with pain, disability, and functional limitation in KOA patients. [ABSTRACT FROM AUTHOR]

The fear-avoidance model is a well-established framework in the understanding of persistent pain. It proposes a dichotomous path: either the context is interpreted as safe; there is no fear reaction and, therefore, the individual engages in active (positive) coping; or the context is interpreted as threatening, leading to a self-reinforcing vicious circle of fear and (negative) avoidance. We propose an embodied interpretation of this phenomenon employing the joint framework of predictive coding and active inference. The key idea is that multisensory integration of exteroceptive, proprioceptive, and interoceptive sensory inputs can lead to dysfunctional experiences of threat in nonthreatening situations. Threat inference can promote fear responses, maladaptive strategies (i.e., avoidance) and self-provides evidence for threat in associated or future contexts, or both. Under this treatment, the prediction of nonrealized threat becomes self-evidencing and context-invariant, and hence self-perpetuating. Safety cues are unable to attenuate the interpretation of the negative context as the dominant inference of the context is threatful and gains more precision and becomes resistant over time. Our model provides an explanation for the emergence of a dysfunctional fear response in the clinical setting despite apparent safety based on modern concepts from theoretical (computational) neuroscience. [ABSTRACT FROM AUTHOR]

Abstract Introduction Fear-avoidance beliefs (FAB) play a crucial role in the treatment outcomes of post-surgery patients. These beliefs can lead to activity avoidance, increased pain, and decreased quality of life. Therefore, accurately measuring these beliefs in Iranian patients is of significant importance. The Fear-Avoidance Belief Questionnaire (FABQ) is a patient-reported questionnaire that evaluates individuals’ FAB. Since the validity and reliability of the Persian version of FABQ (FABQ-P) have not been assessed based on the Iranian population and sociocultural contexts, the current study has been implemented to determine the reliability and validity of the FABQ-P among Iranian post-operative patients by translation and psychometric properties. Methods This methodological study conducted in 2023, a sample of 400 patients who had undergone surgery were selected using a convenience sampling method. The scale used in the study was translated and its psychometric properties were evaluated through network analysis and assessments of construct validity (including exploratory and confirmatory factor analysis), convergent validity, and discriminant validity. Additionally, the study assessed the internal consistency of the scale. Results The MLEFA results with Promax and Kaiser Normalization rotation yielded two factors explaining 57.91% of the variance, encompassing 13 items. Also, the model was approved by CFA. Convergent and discriminant validity have been confirmed through the following criteria: Average Variance Extracted (AVE) exceeding 0.5, Composite Reliability (CR) surpassing 0.7, and Heterotrait-Monotrait Ratio of Correlations (HTMT) equating to 0.597. As for reliability, Cronbach’s alpha, composite reliability (CR), and MaxR for all constructs were greater than 0.7, demonstrating good internal consistency. Conclusion As demonstrated by the results, the FABQ-P has a satisfactory level of reliability along with authentic validity according to the sociocultural contexts of Iranian post-operative patients.

Karolin Teichmüller,1,2 Andrea Kübler,2 Heike L Rittner,1 Gudrun-Karin Kindl1 1University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Centre for Interdisciplinary Pain Medicine, Würzburg, Germany; 2University of Würzburg, Institute of Psychology, Department of Psychology I, Würzburg, GermanyCorrespondence: Gudrun-Karin Kindl, University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Centre for Interdisciplinary Pain Medicine, Oberdürrbacher Str. 6, Würzburg, 97080, Germany, Email Kindl_G@ukw.dePurpose: The Avoidance-Endurance Model postulates fear-avoidance responses and endurance responses as important psychological mechanisms in the development and maintenance of chronic pain. The present study aims to investigate potential differences in avoidance and endurance responses to pain before and with advanced chronification.Patients and Methods: Two samples of adults with non-cancer pain at two different stages of chronicity were compared: One with pain and risk factors for chronicity (n=26, part of the PAIN2020 project) and one with chronic pain (n=33 from a pain day care clinic). The German Pain Questionnaire, the Graded Chronic Pain Scale (GCPS) and medical reports were used to measure duration and severity of pain. Responses to pain were assessed with the Avoidance-Endurance Questionnaire (AEQ) and psychological strain with the Depression, Anxiety and Stress Scales (DASS).Results: Both groups were primarily affected by musculoskeletal pain. Although not yet chronified, the risk group reported comparable GCPS levels of pain intensity and disability. Depression and stress ratings were also similar, except for anxiety, which was significantly elevated in the chronic pain sample (p< .001). The AEQ scales did not differ between groups, neither on any of the fear-avoidance- nor endurance-related dimensions. A post-hoc regression analysis revealed a significant prediction of fear-avoidance by pain-related disability (p< .001). The regression model for endurance responses was not significant.Conclusion: Patients with risk factors of chronification experience substantial pain-related burden. Responses to pain in the realm of the Avoidance-Endurance model do not appear to vary as a function of chronification. While fear-avoidance and pain-related disability correlate positively, endurance could not be associated to any of our variables.Keywords: Avoidance-Endurance Model, fear-avoidance, chronic pain, chronification, PAIN2020

Chronic pain affects individuals’ activity levels. Three activity patterns are observed among individuals with chronic pain: avoidance, overdoing, and regularization. According to fear - avoidance models, kinesiophobia is related to pain severity and disability. Kinesiophobia is a psychological factor that attracts attention in people with persistent pain, is related to the severity and persistence of pain. The aim of this study was to compare demographic and clinical characteristics of individuals with chronic inflammatory low back pain (ILBP) and mechanical low back pain (MLBP), in relation to kinesiophobia, fear-avoidance beliefs, and pain/activity patterns. A total of 89 people (45 MLBP, 44 ILBP) aged 18-65 were included in this cross-sectional study. A Visual Analog Scale (VAS) was used to inquire about for the duration of axial spondylarthritis diagnosis, duration of LBP, duration of morning stiffness, general pain, pain during movement, and night pain. Patients' fear of movement due to pain was assessed with the Tampa Kinesiophobia Scale (TKS), pattern changes in daily activities were assessed with the Pain-Activity Pattern Scale (PAPS), and fear-avoidance was assessed with the Fear-Avoidance Beliefs Questionnaire (FABQ). The scores obtained were compared. There was no statistically significant difference between the MLBP and ILBP groups in terms of age (p=0.202), BMI (p=0.124), gender (0.459), education level (p=0.082) and VAS-movement (p=0.071), FABQ score (0.277), PAPSa (p=0.454), PAPSe (0.596), PAPSs (p=0.247), and TKS score (p=0167). Whereas a statistically significant difference was found between the duration of morning stiffness (p=0.001), pain duration (p=0.018), VAS resting (p=0.001), and VAS night (p=0.001) score. It was observed that high resting and night VAS scores in the ILBP group were not associated with fear-avoidance and kinesiophobia behaviors any more than in the MLBP group. The fear- avoidance and kinesiophobia behaviors of both groups were affected to a similar extent, even though the pain type was different.

Background: Accurate concussion monitoring requires access to preinjury baseline data. This is particularly important in adolescent athletes who have a high risk of concussion and are prone to prolonged recovery. As Rugby Union is governed by similar laws for men and women, it is also an ideal population to rigorously examine the impact of biological sex on concussion symptoms. Aims: To evaluate self-reported concussion symptoms at baseline in adolescent rugby union players, and examine if subtype-specific symptoms are affected by concussion history and biological sex. Methods: Adolescent rugby union players aged 16–18 years were recruited during the 2022–2023 playing season. Participants completed a series of questionnaires covering post-concussion symptoms, concussion clinical profiles, anxiety, depression and fear avoidance behaviours. Independent variables of interest in analysis were biological sex and concussion history. Results: 149 participants (75% male) were included. 42% (63/149) reported at least one previous concussion (average time since concussion: 18.7 months, range 1–72). Adolescents with a concussion history reported significantly higher scores than those with no history, across two clinical profiles (ocular and sleep), concussion symptom severity, and depression, all based on medium effect sizes (SMD 0.3–0.5). Females had significantly higher scores across cognitive/fatigue, ocular and sleep clinical profiles, concussion symptoms, anxiety and depression, each with large effect sizes (SMD > 0.5). Conclusions: Concussion history and sex are associated with higher baseline scores on specific concussion clinical profile, concussion symptom severity, and anxiety symptoms. These findings highlight the importance of considering baseline differences when interpreting post-injury clinical profile symptoms in adolescent rugby players. (Trial registration: ACTRN12622000931774). [ABSTRACT FROM AUTHOR]

AbstractObjectivesMethodsResultsConclusion(1) to represent in pictures a group of items from the International Classification of Functioning (ICF) that represent daily situations; (2) to compare valence and arousal evoked by these pictures between chronic shoulder pain and pain-free control groups and assess self-reports of fear, avoidance, and harm perception.This is a cross-sectional observational study and approved by Research Ethics Committee. Selected pictures representing items from the ICF were judged by members of the general public using an online form. We used the set of International Affective Picture System and the Self-Assessment Manikin to compare valence and arousal between groups. The chronic shoulder pain group answered questions regarding self-reports of fear, avoidance, and harm perception.The protocol consisted of 58 pictures. A repeated measures ANOVA for valence revealed a main effect of group, F(1, 9)=24.81;p < 0.005, and no effect on the arousal, F(1,9)=2.00;p < 0.190. The shoulder pain group judged shoulder pictures more aversive. The picture that represents the movement of carrying on shoulder presented the highest medians of self-reports of fear, avoidance, and harm perception 10(8-10).The pictures represent daily activities that correspond to the items from the ICF. The valence of the shoulder pictures was different between the groups, shoulder pictures were considered more aversive for the group with chronic shoulder pain. The responses of avoidance, fear, and harm perception showed higher median in the carrying on shoulders, hip, and back picture. [ABSTRACT FROM AUTHOR]

The objective of this study is to examine the contribution of pain catastrophising to Axial Spondyloarthritis (axSpA) patient's physical function and to test the mediating role of fear of movement, and uniquely, the contribution of competence frustration to the fear-avoidance model. Participants (N = 98, 70% female, M age = 45.62, SD 12.16) completed an online survey (December 2020–May 2021) distributed in the United Kingdom via the National Axial Spondyloarthritis Society (n ≈ 3500; NASS, 2019). The PROCESS SPSS macro was used to test three mediation models using percentile bootstrap 95% confidence intervals (PBCI). A significant indirect effect on the relationship between pain and physical function via fear of movement (β = 0.10, 95% PBCI = 0.030–0.183) was observed (Model 1). Model 2 showed the relationship between pain catastrophising and physical function to be significantly mediated by fear of movement (β = 0.16, 95% PBCI = 0.005–0.322). Finally, Model 3 showed a significant indirect effect on the relationship between pain catastrophising and physical function via competence frustration (β = 0.15, 95% PBCI = 0.014–0.309) but not through fear of movement (β = 0.062, 95% PBCI = − 0.134 to 0.248). To our knowledge, this is the first study to examine and demonstrate the unique contribution of competence need frustration to the Fear-avoidance model in people that live with axSpA. Identifying modifiable factors that contribute to disease outcomes such as physical function can improve the care and quality of life for people living with a disease currently without a cure. [ABSTRACT FROM AUTHOR]

Chronic pain affects individuals’ activity levels. Three activity patterns are observed among individuals with chronic pain: avoidance, overdoing, and regularization. According to fear - avoidance models, kinesiophobia is related to pain severity and disability. Kinesiophobia is a psychological factor that attracts attention in people with persistent pain, is related to the severity and persistence of pain. The aim of this study was to compare demographic and clinical characteristics of individuals with chronic inflammatory low back pain (ILBP) and mechanical low back pain (MLBP), in relation to kinesiophobia, fear-avoidance beliefs, and pain/activity patterns. A total of 89 people (45 MLBP, 44 ILBP) aged 18-65 were included in this cross-sectional study. A Visual Analog Scale (VAS) was used to inquire about for the duration of axial spondylarthritis diagnosis, duration of LBP, duration of morning stiffness, general pain, pain during movement, and night pain. Patients' fear of movement due to pain was assessed with the Tampa Kinesiophobia Scale (TKS), pattern changes in daily activities were assessed with the Pain-Activity Pattern Scale (PAPS), and fear-avoidance was assessed with the Fear-Avoidance Beliefs Questionnaire (FABQ). The scores obtained were compared. There was no statistically significant difference between the MLBP and ILBP groups in terms of age (p=0.202), BMI (p=0.124), gender (0.459), education level (p=0.082) and VAS-movement (p=0.071), FABQ score (0.277), PAPSa (p=0.454), PAPSe (0.596), PAPSs (p=0.247), and TKS score (p=0167). Whereas a statistically significant difference was found between the duration of morning stiffness (p=0.001), pain duration (p=0.018), VAS resting (p=0.001), and VAS night (p=0.001) score. It was observed that high resting and night VAS scores in the ILBP group were not associated with fear-avoidance and kinesiophobia behaviors any more than in the MLBP group. The fear- avoidance and kinesiophobia behaviors of both groups were affected to a similar extent, even though the pain type was different. [ABSTRACT FROM AUTHOR]

Lihong Bao,1,&ast; Chunfen Peng,2,&ast; Jingting He,2 Chengqin Sun,1 Lijuan Feng,1 Yang Luo1 1Department of Thoracic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China; 2Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Yang Luo; Jingting He, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China, Email yangluo@hust.edu.cn; hejingting@hust.edu.cnBackground: The role of fear-avoidance beliefs (FAB) in patients with chronic pain has been widely confirmed. However, few conclusions have been drawn about its role in postoperative patients.Objective: To explore the characteristics of FAB in postoperative patients after lung surgery as well as the effect of threat learning on FAB.Methods: Between May and September 2022, this study recruited 150 participants who had undergone thoracoscopic surgery. Variables such as age, gender, education, chronic pain, fear of pain, surgery method, pain intensity, FAB, cough, ambulation and threat learning were collected and subjected to correlation analysis and stepwise regression.Results: The correlation analysis revealed that FAB was associated with age (r = − 0.183, p < 0.05), gender (r = − 0.256, p < 0.01), and preoperative FOP-9 (r = 0.400, p < 0.01). Postoperative variables such as pain intensity (r = 0.574, p < 0.01), initiation day of ambulation (r = 0.648, p < 0.01), total numbers of ambulation (r = − 0.665, p < 0.01), and cough performance (r = − 0.688, p < 0.01) were correlated with FAB. Furthermore, FAB was highly correlated with indicators of threat learning: direct (r = 0.556, p < 0.01), observation (r = 0.655, p < 0.01), and instruction (r = 0.671, p < 0.01). The highest variance explanation model of stepwise regression which explained 52.8% of the variance including instruction (B=1.751; p< 0.01), direct (B=1.245; p< 0.01), observation (B=0.768; p< 0.01), age (B=− 0.085; p< 0.01), and surgery method (B=1.321; p< 0.05).Conclusion: Patients commonly experience FAB after lung surgery, which can directly affect their recovery behaviors such as ambulation and active coughing. The formation of FAB is influenced by threat learning, which suggests that controlling threat learning is important in preventing postoperative FAB.Keywords: fear-avoidance, threat learning, fear of pain, postoperative pain, lung surgery

Introduction: Vulvodynia, a chronic genital pain disorder with a high lifetime prevalence among women, has a significant negative impact on both women and their partners. Although there is a growing body of literature on the experiences of women with vulvodynia, there has been little research on the condition's implications for partners and romantic relationships. The aim of this study is to explore how heterosexual couples experience living with vulvodynia. Material and methods: Eight Norwegian women diagnosed with vulvodynia by gynecologists were recruited with their partners (couples aged 19–32 years). Data was collected via individual semi‐structured interviews and analyzed using inductive thematic analysis. Results: Three main themes were identified in the analysis: Mysterious disorder, Social exclusion and Sexual expectations. The results show that the couples struggle with understanding the pain, as well as navigating their social and sexual lives. We discuss these findings in light of a new theoretical model: the fear‐avoidance‐endurance model of vulvodynia. Conclusions: Heterosexual couples living with vulvodynia experience communication difficulties with partners, health professionals, and their social network. This sustains avoidance and endurance behavior, increasing pain and dysfunction over time and giving rise to feelings of powerlessness and loneliness. Social expectations regarding male and female sexuality also promote guilt and shame for both parties in couples affected by vulvodynia. Our results suggest that heterosexual couples living with vulvodynia, as well as health professionals treating them, should be helped to communicate more effectively in order to break vicious circles of maladaptive avoidance and endurance behavior. [ABSTRACT FROM AUTHOR]

Rupal M Patel, Bethany L Anderson, John B Bartholomew Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, USACorrespondence: Rupal M Patel, Email rupal@utexas.eduBackground: Pain catastrophizing is a maladaptive cognitive strategy that is associated with increased emotional responses and poor pain outcomes. Total knee replacement procedures are on the rise and 20% of those who have the procedure go on to have ongoing pain. Pain catastrophizing complicates this pain and management of this is important for recovery from surgery and prevention of chronic pain. This study examines the effect of interventions on PC for patients undergoing total knee replacement (TKR).Methods: Multiple search engines were searched from inception up to March 2021 for relevant studies measuring PC in adults who have undergone TKR. Studies were screened using the Downs and Black Checklist. We included 10 studies (n = 574) which recruited peri surgical TKR participants. Effect sizes were calculated and compared on effect of intervention on PC.Results: Five studies examined the effect of cognitive behavioral therapy-based intervention on PC with low to moderate effects. Two studies examined the effect of a pain neuroscience education on PC with small effects short term. One study examined the effect of hypnotic therapy on PC with small, short-term effect (1 month) but large effect at 6 months. One study compared the effect of an isometric quadricep exercise with auditory and visual feedback on PC to treatment as usual with small, short-term effects. One study compared the effects of an activity and goal setting diary on PC with a moderate effect at 4 weeks.Conclusion: PC is a modifiable characteristic. Several interventions show modest benefit, however more research is needed to aid in clinical decision-making for this population. Interventions are most likely to produce benefits when they are targeted to people with high levels of PC.Keywords: pain catastrophizing, fear-avoidance, fear of pain, psychological, psychosocial, treatment

Kinesiophobia is a common symptom associated with high disability, and has been observed in patients with migraine. However, the association between kinesiophobia and clinical factors in this population is unknown. To assess the fear of falling, dizziness disability, and migraine disability in patients with migraine, considering the presence of kinesiophobia. Eighty patients with migraine completed the Tampa Scale for Kinesiophobia and were divided into two groups according to the questionnaire cutoff point: migraine without kinesiophobia (MoK, n = 39) and migraine with kinesiophobia (MK, n = 41). Fear of falling, dizziness disability, and migraine disability were assessed in both groups using validated questionnaires. The MK group presented higher scores on dizziness disability, fear of falling, and migraine disability compared to the MoK (p <.05). Kinesiophobia can explain 29% of the variance in dizziness disability and 18% of migraine disability. Both kinesiophobia and the presence of dizziness can explain 14% of fear of falling variability. Also, kinesiophobia is associated with the risk of presenting fear of falling (Prevalence Ratio = 2.4, p =.012), and migraine disability (Prevalence Ratio = 2.6, p =.01). The presence of kinesiophobia should be considered in clinical practice when evaluating migraine, as it is associated with increased levels of fear of falling, dizziness disability, and migraine disability. [ABSTRACT FROM AUTHOR]

Background: Fear-avoidance is one of the factors associated with chronic pain. However, it remains unclear whether the association between fear-avoidance and pain depends on sex. The present study aimed to investigate whether the association between fear-avoidance and pain intensity differed between men and women in chronic pain patients. Additionally, the potential confounding effect of affective experiences on the association between fear-avoidance and pain intensity was analyzed. Method: This cohort study included hospital referred chronic pain patients (n = 45). Short momentary assessment questions according to the experience sampling method (ESM) were used to repeatedly assess patients' pain intensity, level of fear-avoidance and positive as well as negative affect during their daily life. Linear mixed-effects models were applied in the statistical analysis. Unadjusted and adjusted models were made, in which the latter corrected for statistically significant affective experiences and baseline variables, taking the Aikake Information Criterion into account to assess a better model of fit. Results: The results demonstrated an association between fear-avoidance and pain intensity that differed for men and women. In men (n = 13), no association between these variables was found (−0.04 (95% CI: −0.14, 0.06) with a p-value of 0.48), whereas in women (n = 32), an increase in fear-avoidance was associated with a (slight) increase in pain intensity (0.18 (95% CI 0.06, 0.30) with a p-value of 0.003). Affect did not confound the above-mentioned findings. Conclusion: Our data supports previous research highlighting the importance of sex differences in pain experience. These findings may be relevant for clinicians to consider more personalized (i.e., gender specific) pain management in chronic pain patients. [ABSTRACT FROM AUTHOR]

Objectives: The Tampa Scale of Kinesiophobia (TSK) evaluates pain associated fear, which is considered an important factor in the cognitive assessment of musculoskeletal pain according to the biopsychosocial model. The aim of this study was to validate the Greek version of the TSK (TSK-GR) in a population suffering from chronic low back pain. Methods: Following Institutional Review Board's approval (ref.: 6/16-2-2018), 70 consecutive patients with low back pain, lasting more than three months, completed the TSK-GR together with the Greek versions of the Hospital Anxiety & Depression Scale (HADs-GR), Fear Avoidance Beliefs Questionnaire (FABQ-GR), Pain Locus of Control (PLC-GR) and visual analogue scale for pain (VAS). A subgroup of 20 patients completed the TSK-GR (48 hours) twice (test-retest reliability). Construct validity was evaluated through the a priori hypothesis of correlation with the FABQ-GR, HADs-GR and VAS, while discriminant construct validity through the lack of correlation with the PLC-GR. The Cronbach's alpha (a), the Pearson's correlation coefficient (r) and the Intraclass Correlation Coefficient (ICC) statistics were used for analyses. Results: Internal consistency and test-retest reliability were satisfactory (Cronbach's a=0.74 and ICC=0.78). The construct validity of the TSK-GR was shown through its association with both FABQ subscales (FABQ-work: r=0.48, p<0.001, and FABQ-physical: r=0.51, p<0.001), with both HADs subscales (HADs-depression: r=0.45, p<0.001, and HADs-anxiety: r=0.34, p<0.005) and with the VAS (r=0.62, p<0.001). Discriminant construct validity was shown through the lack of association between TSK-GR and the PLC-GR. Conclusions: This study provided evidence for the validity and reliability of the Greek version of TSK in patients with chronic low back pain. [ABSTRACT FROM AUTHOR]

Body mass index, pain, female sex, and age have been reported as predictors of physical activity in patients with lumbar spinal stenosis (LSS). However, no reports have examined the psychological factors associated with physical activity in people with LSS. To use psychological assessments to identify the factors associated with physical activity measured as daily step count in people with LSS. Seventy-one patients who received outpatient physical therapy were included. All patients completed the following scales at baseline: Zurich Claudication Questionnaire; self-paced walking test (SPWT); numerical rating scale of low back pain, leg pain, and leg numbness; Hospital Anxiety and Depression Scale (HADS); Pain Catastrophizing Scale; Pain Anxiety Symptoms Scale (PASS-20); and Tampa Scale for Kinesiophobia. Physical activity was measured using a pedometer as the average number of daily steps. Daily step count was significantly associated with age, number of stenoses, severity of stenosis at L3–L4, walking distance on the SPWT, PASS-20 total score, cognitive anxiety, escape/avoidance, fear, and HADS depression score (p <.05). Multiple regression analysis showed that age, severity of stenosis at L3–L4, walking distance on the SPWT, and PASS-20 fear predicted daily step count (r2 = 0.414). Older age, fewer stenoses, less severe stenosis at L3–L4, lower walking capacity, higher anxiety, and fear-avoidance beliefs about pain and depression are more closely associated with lower daily step count than are back and leg pain. Assessment and treatment of psychological factors might help to increase physical activity in patients with LSS. [ABSTRACT FROM AUTHOR]

Chronic pain due to musculoskeletal injury is one of the leading causes of disability and reduced combat readiness in the U.S. Army. Unidimensional pain management systems are not effective in addressing the complex phenomenon of pain-related disability. Growing evidence has supported use of the Fear Avoidance Model (FAM) as a suitable model to address pain-related disability and chronicity from a multidimensional pain neuroscience approach. While several fear avoidance measurement tools exist, one that addresses the complexity of the Army environment encouraged the authors to develop and test the reliability and validity of a military specific questionnaire. This study developed and validated an Army specific fear avoidance screening, the Return to Duty Readiness Questionnaire (RDRQ), which subsequently demonstrated good psychometric properties. Reliability coefficients demonstrate high internal consistency values both during pilot study (α = 0.96) and validation study (α = 0.94, ωt = 0.94). A Correlation Coefficient of 0.74 when compared with the Fear Avoidance Components Scale (FACS) suggests good concurrent validity. Future study should include replication in a new army population, investigation of responsiveness, test-retest reliability, structural validity and establishing severity scores with minimal clinically important differences to enhance utility.

Adverse childhood experiences (ACEs) increase the likelihood of reduced physical and psychological health in adulthood. Though understanding and psychological management of traumatic experiences is growing, the empirical exploration of ACEs and physical clinical outcomes remains under-represented and under-explored. This topical review aimed to highlight the role of ACEs in the experience of chronic pain, pain management services and clinical decision making by: (1) providing an overview of the relationship between ACEs and chronic pain; (2) identifying biopsychosocial mechanisms through which ACEs may increase risk of persistent pain; (3) highlighting the impact of ACEs on patient adherence and completion of pain management treatment; and (4) providing practical clinical implications for pain management. Review findings demonstrated that in chronic pain, ACEs are associated with increased pain complications, pain catastrophizing and depression and the combination of these factors further heightens the risk of early treatment attrition. The pervasive detrimental impacts of the COVID-19 pandemic on ACEs and their cyclical effects on pain are discussed in the context of psychological decline during long treatment waitlists. The review highlights how people with pain can be further supported in pain services by maintaining trauma-informed practices and acknowledging the impact of ACEs on chronic pain and detrimental health outcomes. Clinicians who are ACE-informed have the potential to minimize the negative influence of ACEs on treatment outcomes, ultimately optimizing the impact of pain management services.

Background: Chronic pain leads to extreme form of fear of movement, known as kinesiophobia. We aimed at the linguistic andcultural adaption of the Tampa Scale of Kinesiophobia (TSK) into the Arabic language, followed by the evaluation of its psychometric properties. Methods: The Arabic translation of TSK was performed by two independent translators. Next, the concise translation, developed from the two translations, was retranslated to English, and compared with the original questionnaire. The reliability and validity of the Arabic form of TSK was assessed on patients with LBP, admitted to the out-patient clinics in Prince Mutaib Bin Abdul Aziz Hospital, Al Jouf, Saudi Arabia. Apart from the demographic data, TSK and five other questionnaires were used to measure the level of kinesiophobia. Test-retest and Cronbach’s alpha was used to assess the reliability and internal consistency. Spearman’s correlation was performed for construct validation. Results: Eighty-two patients were enrolled. An excellent test-retest reliability was observed after 2 days (ICC=0.91; 95% CI: 0.90-0.92) as well as after 14 days (ICC=0.87; 95% CI: 0.84-0.90). The internal consistency of the translated version was also high (Cronbach’s alpha=0.83). The correlation between TSK and FABQ was moderate (r=0.68), and fair for NRS, RMDQ, and MODI (r=0.47, 0.37, and 0.42, respectively). The sensitivity to change was found to be low. Conclusions: The robustness and sustainability of the translated Arabic version of TSK suggested that this questionnaire is a reliable and valid tool for the measurement of kinesiophobiain the Arab population suffering from LBP.

Examine injury-related psychological distress and association with perceived running ability in injured runners. Prospective longitudinal study. Forty-three patients with a running-related injury. Data collection at initial physical therapy visit and 12–16 weeks later included Optimal Screening for Prediction of Referral and Outcome - Yellow Flag (OSPRO-YF) and Athlete Fear Avoidance Questionnaire (AFAQ) for injury-related psychological distress, and University of Wisconsin Running and Recovery Index (UWRI) for perceived running ability. OSPRO-YF composite score, total yellow flags, and yellow flags in each domain (negative mood, fear-avoidance, positive affect/coping) were calculated. UWRI score and OSPRO-YF composite score and yellow flags significantly improved over time, while AFAQ score and yellow flags in OSPRO-YF negative mood domain did not. AFAQ scores were significantly correlated with UWRI score at baseline, follow-up and change over time, while OSPRO-YF composite score and yellow flags were not. Baseline OSPRO-YF composite score and AFAQ score were not correlated with follow-up UWRI score. Injury-related psychological distress is elevated when injured runners start rehabilitation, and generally improves; however, negative mood and athletic fear-avoidance may persist. Higher athletic fear-avoidance is associated with lower perceived running ability at the same time point or interval. • Injured runners exhibit psychological distress at the start of rehabilitation. • Negative mood and athletic fear-avoidance beliefs may persist in some injured runners. • Higher athletic fear-avoidance is associated with lower perceived running ability. [ABSTRACT FROM AUTHOR]

Muhammad Naseeb Ullah Khan,1 Natalie MV Morrison,2,3 Paul W Marshall1 1School of Health Sciences, Western Sydney University, Sydney, NSW, Australia; 2School of Medicine, Western Sydney University, Sydney, NSW, Australia; 3Translation Health Research Institute, Western Sydney University, Sydney, NSW, AustraliaCorrespondence: Muhammad Naseeb Ullah Khan Tel +61 2 4620 3915Email dr.zyee@gmail.comBackground: The relationship of low back pain, the world’s top disabling condition, with functional disability is often explained by the mediation effect of fear, catastrophizing, and psychological distress. These relationships have not been explored within chronic back pain patients from a low socio-economic, predominantly Muslim country. Thus, it was unclear whether previously established pathways would be consistent in Pakistani pain patients to help guide Pakistani clinicians caring for back pain patients. This cross-sectional study translated English versions of questionnaires within the fear-avoidance model into Urdu, tested the clinimetric properties of the Urdu versions for people with chronic low back pain (CLBP) in Pakistan, and performed mediation analysis to investigate pathways of the fear-avoidance model.Methods: Translation of questionnaires was completed in 4 steps using the forward-backward technique, with subsequent analyses for internal consistency (Cronbach’s α), construct validity (Pearson’s r-value), and test–retest reliability (ICC r-value). Multiple mediation analysis with bootstrapping was performed to analyze pathways within the fear-avoidance model from the Urdu translated questionnaires.Results: A total of 151 people from Pakistan with CLBP completed the questionnaires, with good results for internal consistency (r > 0.85), convergent validity (r > 0.59), and test–retest reliability (ICC r > 0.85). The association of pain with disability was significant (B=2.36, r2 = 0.19, p< 0.001), and the indirect effect of the mediators explained 81% of pain intensity’s total effect on disability. All mediators, apart from physical activity-related fear-avoidance beliefs, were significant mediators of the effect of pain intensity on disability.Conclusion: The Urdu versions of the fear-avoidance questionnaires show good clinimetric properties for use in clinical settings and research in Pakistan. These analyses support existing data for the mediation effect of catastrophizing, psychological distress, and self-efficacy on pain-related disability, and extends these findings to suggest that fear about work may be more important in a relatively lower socioeconomic sample of pain patients.Keywords: chronic low back pain, Urdu, mediation analysis, fear-avoidance, catastrophizing, Pakistan

Abstract Background Pain-related fear-avoidance (FA) is a common problem affecting many patients with painful medical conditions. As there is great interest in the clinical importance of the relationship between FA and disability, several questionnaires have been developed to measure FA. The Fear-Avoidance Components Scale (FACS) is a recently developed patient-reported instrument that addresses critical issues not previously considered in previous FA-related questionnaires. The original English version of the FACS demonstrated good reliability, internal consistency, and construct, criterion, and predictive validity. Two factors were determined: General Fear Avoidance and Types of Activities That are Avoided. The aim of this study was to to translate the FACS into European-style Spanish (FACS-Sp), and validate its psychometric properties. Methods This two-stage psychometric study included 330 subjects with various chronic musculoskeletal pain disorders. An initial translation and cross-cultural adaptation of the FACS, from English to Spanish, was performed. Then, critical psychometric properties were analysed, including internal consistency by Cronbach’s α coefficients, structural validity from the Maximum Likelihood Extraction (MLE), and convergent validity by Pearson correlation with the Central Sensitization Inventory (CSI). Results This study reports for the first time the psychometric properties of the Spanish version of the FACS. Total scores ranged from 0 to 88 points, with a mean of 30.49 (±17.18). The FACS-Sp showed a high internal consistency for factor 1 (α = 0.902) and factor 2 (α = 0.88). Factor structure was two-dimensional and supported structural validity, accounting for 48.75% of the total variance. Convergent validity analysis found a significant Pearson correlation r = 0.414. Conclusion This study reports for the first time the psychometric properties of the Spanish version of the FACS-Sp. Psychometric properties supported the validation of FACS-Sp and ensured the conceptual equivalence with the original English version. In primary care and chronic pain rehabilitation, FA assessment is crucial for clinical decision-making and treatment guidance. The FACS-Sp offers a new measure of FA in Spanish speaking populations. Future research on the FACS-Sp should evaluate test-retest reliability, treatment responsiveness and psychometric comparisons with other translated versions.

Takahiko Yoshimoto,1,2 Hiroyuki Oka,2 Tomoko Fujii,2 Kayo Kawamata,2 Akatsuki Kokaze,1 Yoshiko Koyama,3,4 Ko Matsudaira21Department of Hygiene, Public Health and Preventive Medicine, Showa University School of Medicine, Tokyo, Japan; 2Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical & Research Center, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; 3Department of Physical Therapy, Faculty of Health Sciences, Kinjo University, Ishikawa, Japan; 4Ishikawa Occupational Health Support Center, Ishikawa, JapanPurpose: Care workers at nursing care facilities have high rate of low back pain (LBP). Although increasing evidence has revealed the important role of psychosocial factors in chronic LBP, factors associated with chronic LBP interfering with work have not been fully investigated in Japanese workers at nursing care facilities. The present study aimed to determine the prevalence of chronic LBP interfering with work and related factors of chronic LBP including psychosocial factors, among workers at nursing care facilities.Material and methods: Eligible participants in the present study were Japanese workers at 95 nursing care facilities in Ishikawa Prefecture (n=2,242). Of these, 1,345 participants completed a self-administered questionnaire that included the following items: individual characteristics, severity of LBP, sleep problem, fear-avoidance beliefs (Tampa Scale for Kinesiophobia: TSK), STarT Back Screening Tool (SBST), fatigue, somatizing tendency, and work-related stress such as job satisfaction, job demand, interpersonal stress at work, and social support. The logistic regression analysis was used to assess factors associated with chronic disabling LBP.Results: Of participants who completed the questionnaires, 159 (11.8%) reported chronic LBP that interfered with their work. The multivariable analysis of related-factors of chronic disabling LBP found statistically significant associations with the following: high score of psychological subscale in SBST (adjusted odds ratio [aOR]: 5.83, 95% confidence interval [CI]: 3.55–9.59), high score of TSK (aOR: 1.08, 95% CI: 1.05–1.13), and high somatizing tendency (aOR: 2.07, 95% CI: 1.31–3.23).Conclusion: Psychological factors, including fear-avoidance beliefs or somatizing tendency, showed significant association with chronic LBP that interfered with work, among workers at nursing care facilities. Our results suggest that these factors would need to be considered in addition to screening for the risk factors of LBP chronicity by SBST when evaluating workers with chronic disabling LBP.Keywords: low back pain, care worker, nursing care facility, psychological factor, fear-avoidance, somatizing tendency

Background Efforts to identify specific variables that impact most on outcomes from interdisciplinary pain rehabilitation are challenged by the complexity of chronic pain. Methods to manage this complexity are needed. The purpose of the study was to determine the network structure entailed in a set of self-reported variables, examine change, and look at potential predictors of outcome, from a network perspective. Methods In this study we apply network analysis to a large sample of people seeking interdisciplinary pain treatment (N = 2,241). Variables analyzed include pain intensity, pain interference, extent of pain, depression, anxiety, insomnia, and psychological variables from cognitive behavioral models of chronic pain. Results We found that Acceptance, Pain Interference, and Depression were key, "central," variables in the pretreatment network. Interestingly, there were few changes in the overall network configuration following treatment, specifically with respect to which variables appear most central relative to each other. On the other hand, Catastrophizing, Depression, Anxiety, and Pain Interference each became less central over time. Changes in Life Control, Acceptance, and Anxiety were most strongly related to changes in the remainder of the network as a whole. Finally, no network differences were found between treatment responders and non-responders. Conclusions This study highlights potential future targets for pain treatment. Further application of a network approach to interdisciplinary pain rehabilitation data is recommended. Going forward, it may be better to next do this in a more comprehensive theoretically guided fashion, and ideographically, to detect unique individual differences in potential treatment processes. [ABSTRACT FROM AUTHOR]

Background: Concussion is common, and up to 30% of youth develop persistent symptoms. Preliminary data suggests treatment with rehabilitative exercise is beneficial, but most programs require frequent in-person visits, which is challenging for youth in rural areas, and has been made more difficult for all youth during the COVID-19 pandemic. We have adapted an exercise intervention to be delivered via telehealth using Zoom and personal fitness devices, which could ensure access to this type of treatment.Objective: The goal of this study was to assess feasibility and acceptability of a telehealth delivered exercise intervention for concussion, the Mobile Subthreshold Exercise Program (MSTEP), and collect pilot data regarding efficacy.Materials and Methods: All youth received the 6-week MSTEP intervention which included wearing a Fitbit and setting exercise heartrate and duration goals weekly over Zoom with the research assistant. Youth completed standardized measures of concussive symptoms (Health Behavior Inventory, HBI), fear-avoidance (Fear of Pain Questionnaire, FOPQ) and health-related quality of life (Pediatric Quality of life Assessment, PedsQL), as well as a structured qualitative exit interview. We examined change in measures over time using mixed effects modeling, controlling for age, sex, prior concussion and duration of symptoms. We coded qualitative interviews using Thematic analysis.Results: We recruited 19 subjects, 79% female with average age 14.3 (SD 2.2) and mean duration of symptoms 75.6 days (SD 33.7). Participants wore the Fitbit on 80% of days, and completed 94% of surveys and 96% of Zoom calls. Concussive symptoms (HBI) decreased significantly over the 6 week intervention (−10.6, 95%CI: −16.0 to −5.1) as did fear-avoidance (−21.6, 95%CI: −29.8 to −13.5). PedsQL improved significantly during the same time period (+15.1, 95%CI: 8.6–21.6). Approximately three-quarters (76%) of youth rated their care as “excellent.” Participants appreciated the structure of the guided exercise program and the support of the RA. They also enjoyed being able to track their progress with the Fitbit.Conclusion: This study provides evidence for the feasibility and acceptability of a telehealth delivered rehabilitative exercise intervention for youth with concussion. Further research utilizing a randomized controlled trial is needed to assess efficacy.Clinical Trial Registration:https://clinicaltrials.gov, identifier: NCT03691363. https://clinicaltrials.gov/ct2/show/NCT03691363

Abstract Background The role of avoidance and endurance behaviour is well established in chronic musculoskeletal pain, but less is known about its significance in migraine. Methods The Avoidance-Endurance Questionnaire behavioural subscales, the Pain Disability Index (PDI), the Migraine Disability Assessment Scale (MIDAS) and the Hospital Anxiety and Depression Scale (HADS) were obtained from 128 migraine patients (90 episodic, 38 chronic). Sixty nine of them were re-evaluated after 3–6 months. Results At baseline, there were positive relations between avoidance (especially social avoidance behaviour) and pain-related disability as assessed by the PDI (Wald χ2 [1] = 32.301, p

The Fear-Avoidance Model was developed with patients who had sustained neck and back injuries and describes a cascade of events after pain that is perceived as threatening, which may lead to avoidance of valued and meaningful life activities. The literature examining burn survivors suggests they may experience fear-avoidance, however, their lived experience has yet to be thoroughly explored and the evaluation tool that has been used is four items extracted from the Tampa Scale of Kinesiophobia that were modified for burn survivors, but never formally validated with this population. Therefore, the aim of this study was to explore, through a mixed methods approach, the lived experience of burn survivors with respect to fear-avoidance and determine whether the reduced four question Tampa Scale of Kinesiophobia (4TSK) reflects and accurately measures their experience. Burn survivors (n = 17) who had undergone surgical debridement and grafting were recruited. They completed the reduced 4TSK and participated in an in-depth interview to explore their lived experience regarding fear-avoidance and their opinions on the relevance of the questions. The interviews were analyzed using a thematic-analysis approach. Five major themes that represented the lived experience of fear-avoidance in burn survivors were identified: perceived vulnerability to re-injury, others as fear influencers, difficulties & hardships during recovery, engagement in activity, and active thoughts. Based upon the interviews researchers identified 9 potential fear-avoidant participants, which differed from the screening results from the reduced 4TSK (n = 12). Overall, this study demonstrated the potential uniqueness of the burn survivor population and provided insight into their lived experience of fear of movement or activities. [ABSTRACT FROM AUTHOR]

Purpose: Many patients retain sedentary lifestyles after lumbar surgery and incur increased risks of adverse health outcomes. The goal of this study was to assess patients' perspectives about postoperative physical activity.Methods: During routine post-lumbar surgery visits in a tertiary care center, 260 patients were asked open-ended questions about their spine and physical activity. Three investigators reviewed responses and determined themed categories. Patients also completed surveys measuring disability, depressive symptoms, anxiety, and fear-avoidance of physical activity. Surgical complexity was assigned based on operative features.Results: Mean age was 63, and 53% were men. Thirty-nine percent thought walking was good for the spine, particularly among those with less fear-avoidance, less disability, and less complex surgery. Spine benefits were cited (42%) for the short-term ("faster recovery") and long-term ("decreases chances of another surgery"), particularly by younger patients. To increase activity, patients suggested spine-specific techniques (35%, "use railings") and advised caution (24%, "pace yourself"). The major deterrent was persistent back pain (36%) particularly for those with worse disability, and more depressive symptoms, anxiety, complex surgery, and fear-avoidance. Our findings consistently fit with the Social Cognitive Theory of health behavior which posits a dynamic three-way interaction of personal factors, environmental influences, and behavior.Conclusions: Patients acknowledge short- and long-term benefits of physical activity for their spine and overall health; however, many are deterred from increasing activity by spine-related concerns. Interventions to improve physical activity should foster self-efficacy and self-direction and should be reinforced by members of the spine care team who are knowledgeable about prudent activities. [ABSTRACT FROM AUTHOR]

Objectives: In non-athletes, fear-avoidance and endurance-related pain responses appear to influence the development and maintenance of low back pain (LBP). The avoidance-endurance model (AEM) postulates three dysfunctional pain response patterns that are associated with poorer pain outcomes. Whether comparable relationships are present in athletes is currently unclear. This cross-sectional case-control study explored frequencies and behavioral validity of the AEM-based patterns in athletes with and without LBP, as well as their outcome-based validity in athletes with LBP. Methods: Based on the Avoidance-Endurance Fast-Screen, 438 (57.1% female) young adult high-performance athletes with and 335 (45.4% female) without LBP were categorized as showing a "distress-endurance" (DER), "eustress-endurance" (EER), "fear-avoidance" (FAR) or "adaptive" (AR) pattern. Results: Of the athletes with LBP, 9.8% were categorized as FAR, 20.1% as DER, 47.0% as EER, and 23.1% as AR; of the athletes without LBP, 10.4% were categorized as FAR, 14.3% as DER, 47.2% as EER, and 28.1% as AR. DER and EER reported more pronounced endurance- and less pronounced avoidance-related pain responses than FAR, and vice versa. DER further reported the highest training frequency. In athletes with LBP, all dysfunctional groups reported higher LBP intensity, with FAR and DER displaying higher disability scores than AR. Conclusions: The results indicate that also in athletes, patterns of endurance- and fear-avoidance-related pain responses appear dysfunctional with respect to LBP. While EER occurred most often, DER seems most problematic. Implications: Endurance-related pain responses that might be necessary during painful exercise should therefore be inspected carefully when shown in response to clinical pain. [ABSTRACT FROM AUTHOR]

Negative pain beliefs are associated with adverse pain outcomes; however, less is known regarding how positive, adaptive factors influence pain and functioning. These relationships are especially important to examine in older adults with pain, given increased disability and functional limitations in this population. We investigated whether pain resilience moderated the relationships between negative pain beliefs (fear-avoidance, pain catastrophizing) and pain outcomes (functional performance, movement-evoked pain) in sixty older adults with low back pain. Higher pain resilience was associated with lower fear-avoidance (p <.05) and pain catastrophizing (p =.05). After controlling for demographic variables, higher fear-avoidance (p =.03) and catastrophizing (p =.03) were associated with greater movement-evoked pain in individuals with low pain resilience, but not among those high in resilience. No significant moderation effects were observed for functional performance. Resilience may attenuate the relationship between negative psychological processes and pain-related disability, highlighting the need for interventions that enhance pain resilience in older adults. [ABSTRACT FROM AUTHOR]

Diagnostic uncertainty, the perceived lack of an accurate explanation of the patient’s health problem, remains relatively unstudied in children. This study examined the prevalence, familial concordance, and correlates of diagnostic uncertainty in children and their parents presenting to a multidisciplinary pain clinic in the United States. One hundred and twenty-six parents and 91 of their children (Mage = 13.93 years, range = 8–18 years) completed a brief three-item measure of diagnostic uncertainty, as well as measures of pain-related distress and functioning. Forty-eight percent of children and 37% of parents believed something else was going on with the child’s pain that doctors had not found out about yet. Across the three items, 66%–77% of children and their parents agreed in their endorsement of diagnostic uncertainty. Parents who believed that something else was going on with their child’s pain had children with higher avoidance of pain-related activities (F = 5.601, p = 0.020) and lower pain willingness (F = 4.782, p = 0.032). Neither parent nor child diagnostic uncertainty was significantly related to the child’s pain-related functioning. Diagnostic uncertainty, particularly in parents, is relevant in the experience of pediatric chronic pain and warrants further investigation as both a risk factor and therapeutic target. [ABSTRACT FROM AUTHOR]

Background: The fear-avoidance model of chronic pain holds that individuals who catastrophize in response to injury are at risk for pain-related fear and avoidance behavior, and ultimately prolonged pain and disability.Purpose: Based on the hypothesis that the predictive power of the fear-avoidance model would be enhanced by consideration of positive psychological constructs, the present study examined inclusion of pain resilience and self-efficacy in the model.Methods: Men and women (N = 343) who experienced a recent episode of back pain were recruited in a longitudinal online survey study. Over a 3-month interval, participants repeated the Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Pain Self-Efficacy Questionnaire, the McGill Pain Questionnaire, and NIH-recommended measures of pain, depressive symptoms, and physical dysfunction. Structural equation modeling assessed the combined contribution of pain resilience and pain catastrophizing to 3-month outcomes through the simultaneous combination of kinesiophobia and self-efficacy.Results: An expanded fear-avoidance model that incorporated pain resilience and self-efficacy provided a good fit to the data, Χ2 (df = 14, N = 343) = 42.09, p = .0001, RMSEA = 0.076 (90% CI: 0.05, 0.10), CFI = 0.97, SRMR = 0.03, with higher levels of pain resilience associated with improved 3-month outcomes on measures of pain intensity, physical dysfunction, and depression symptoms.Conclusions: This study supports the notion that the predictive power of the fear-avoidance model of pain is enhanced when individual differences in both pain-related vulnerability (e.g., catastrophizing) and pain-related protective resources (e.g., resilience) are considered. [ABSTRACT FROM AUTHOR]

Background and aims: In the spring of 2019, Professor Steven J. Linton, the founder of the Center for Health and Medical Psychology (CHAMP) at Örebro University, Sweden, formally retired. As a tribute to his scholarly work covering decades of influence and inspiration to the field of pain psychology, the research center organized a topical conference titled "Pain in the 21st century: Where do we come from and where are we going?", which resulted in this state-of the-art synthesis. The aim of this declaration is to highlight lessons learned but not in the least is meant to inspire and guide our continued journey forward, developing pain psychology into the 21st century. Methods: Several collaborators of Professor Linton have summarized and reflected on the current state-of-the-art of pain psychology from the perspective of his input to the field, as well as on developments from the last years of advancements in pain psychology. Results: The topics have been divided into six themed sections covering the fear avoidance model, transdiagnostics, secondary prevention, risk- and protective factors, communication and contextual factors. The sections cover a broad spectrum, from basic experimental studies, integrating emotion and motivational theories into current theoretical models, to applied research on the effect of early interventions as well as sophisticated emotion-focused treatment models for pain patients with concurrent emotional ill-health. Conclusions: There have been major advancements within pain psychology research during the last decades, moving the field towards a more comprehensive picture, taking emotional and motivational aspects into account to understand pain sufferers. Although psychologically informed interventions in general mainly focus on the individual, it has been put forward that pain management is highly influenced by the surrounding environment, including communication with health care providers, and the occupational and social context. Implications: Professor Steven J. Linton has been at the forefront of pain psychology research during the last decades, and inspired by his work this journey will continue into the 21st century, with the ultimate goal of enhancing the understanding and treatment for all people suffering from persistent and disabling pain. [ABSTRACT FROM AUTHOR]

Pain-related fear and avoidance are increasingly demonstrated to play an important role in adult and childhood chronic pain. The Fear of Pain Questionnaire for Children (FOPQC) is a 24-item measure of pain-related fear-avoidance in youth that has demonstrated good indices of reliability and validity, treatment responsiveness, and associations with brain circuitry alterations. This study describes the development and psychometric examination of the FOPQC-SF, a short form of the original measure. We selected 10 items for the short form that best represented the content and 2-factor (fear and avoidance) structure of the original measure from a cohort of 613 youth (Mage = 14.7 years) with chronic pain. Next, confirmatory factor analyses from a second sample of 526 youth (Mage = 14.7 years) with chronic pain who completed the FOPQC-SF supported the original 2-factor model but indicated that one item should be moved to the avoidance subscale. The FOPQC-SF demonstrates strong internal consistency and moderate-to-strong construct and criterion validity. The 3-month test-retest reliability estimates (N = 94) were strong, and there was preliminary evidence of responsivity to change. To aid integration into intervention trials and clinical practice, we provide clinical reference points and a criterion to assess reliable change. The short form could be used for rapid identification of pain-related fear and avoidance in youth during clinic evaluations, and is optimized for clinical registries. [ABSTRACT FROM AUTHOR]

Objective: To evaluate feasibility and acceptability of a sub-threshold exercise program with minimal in-person visits to treat youth with persistent sport-related concussion, and explore efficacy for improving concussive symptoms, health-related quality of life, and fear-avoidance.Study design: We conducted a pilot randomized controlled trial comparing a 6 week sub-threshold exercise program requiring only two in-person visits to active control (stretching) for 12–18 year old youth with persistent sport-related concussion. We measured moderate-to-vigorous physical activity pre- and post-intervention using accelerometry, and increased goals weekly via phone contact. We examined feasibility and acceptability using qualitative interviews. We used exponential regression to model differences in trajectory of concussive symptoms by experimental group, and linear regression to model differences in trajectory of health-related quality of life and fear-avoidance of pain by experimental group.Results: Thirty-two subjects randomized, 30 completed the study (n = 11 control, n = 19 intervention), 57% female. Youth and parents reported enjoying participating in the study and appreciated the structure and support, as well as the minimal in-person visits. Exponential regression modeling indicated that concussive symptoms declined more rapidly in intervention youth than control (p = 0.02). Health-related quality of life and fear-avoidance of pain improved over time, but were not significantly different by group.Conclusions: This study indicates feasibility and potential benefit of a 6 week subthreshold exercise program with minimal in-person visits for youth with persistent concussion. Potential factors that may play a role in improvement such as fear-avoidance deserve further study.

Background: Pain-related fear-avoidance (FA) is a common problem affecting many patients with painful medical conditions. As there is great interest in the clinical importance of the relationship between FA and disability, several questionnaires have been developed to measure FA. The Fear-Avoidance Components Scale (FACS) is a recently developed patient-reported instrument that addresses critical issues not previously considered in previous FA-related questionnaires. The original English version of the FACS demonstrated good reliability, internal consistency, and construct, criterion, and predictive validity. Two factors were determined: General Fear Avoidance and Types of Activities That are Avoided. The aim of this study was to to translate the FACS into European-style Spanish (FACS-Sp), and validate its psychometric properties. Methods: This two-stage psychometric study included 330 subjects with various chronic musculoskeletal pain disorders. An initial translation and cross-cultural adaptation of the FACS, from English to Spanish, was performed. Then, critical psychometric properties were analysed, including internal consistency by Cronbach's α coefficients, structural validity from the Maximum Likelihood Extraction (MLE), and convergent validity by Pearson correlation with the Central Sensitization Inventory (CSI). Results: This study reports for the first time the psychometric properties of the Spanish version of the FACS. Total scores ranged from 0 to 88 points, with a mean of 30.49 (±17.18). The FACS-Sp showed a high internal consistency for factor 1 (α = 0.902) and factor 2 (α = 0.88). Factor structure was two-dimensional and supported structural validity, accounting for 48.75% of the total variance. Convergent validity analysis found a significant Pearson correlation r = 0.414. Conclusion: This study reports for the first time the psychometric properties of the Spanish version of the FACS-Sp. Psychometric properties supported the validation of FACS-Sp and ensured the conceptual equivalence with the original English version. In primary care and chronic pain rehabilitation, FA assessment is crucial for clinical decision-making and treatment guidance. The FACS-Sp offers a new measure of FA in Spanish speaking populations. Future research on the FACS-Sp should evaluate test-retest reliability, treatment responsiveness and psychometric comparisons with other translated versions. [ABSTRACT FROM AUTHOR]

Background and aims: Pain catastrophizing has consistently been related to a variety of negative outcomes within chronic pain conditions, but competing models exist explaining the role of catastrophizing. According to the fear-avoidance model (FAM), catastrophizing is primarily related to the appraisal of pain (i.e. "intrapersonal"), whereas the communal coping model (CCM) suggests that catastrophizing is a strategy to elicit support (i.e. "interpersonal"). In order to examine the interpersonal nature of catastrophizing, this cross-sectional study examined interpersonal problems as a predictor of pain catastrophizing in a sample of patients (n = 97) with chronic pain. Methods: Self-report data was taken from patients entering a multidisciplinary, inpatient rehabilitation program. The four quadrants of the Inventory of Interpersonal Problems circumplex model (Hostile-Dominant, Hostile-Submissive, Friendly-Submissive, Friendly-Dominant) were used as predictors of pain catastrophizing in a series of separate, hierarchical regression analyses. Results: After controlling for relevant confounding variables such as demographics (gender, age), pain severity, psychiatric symptoms (anxiety/depression, fatigue, insomnia), adverse life experiences and perceived social support, higher levels of Hostile-Dominant interpersonal problems predicted higher levels of pain catastrophizing (p ≤ 0.01, d = 0.56). Conclusions: The results add support to the notion that pain catastrophizing may serve a communicative functioning, as predicted by the CCM, with cold, dominant and controlling behaviors as a maladaptive interpersonal strategy to elicit support. It may thus be useful to consider the broader interpersonal context of the individual, and not only the patient's appraisal of pain, when conceptualizing the role of pain catastrophizing in patients with chronic pain. Implications: Future psychosocial research and treatment of chronic pain could be informed by including interpersonal theory as a useful theoretical framework, which may help shed more light on how interpersonal problems relates to pain catastrophizing. [ABSTRACT FROM AUTHOR]

Background Context: Chronic low back pain (CLBP) is a major health problem. Identifying prognostic factors is essential for identifying people at risk of developing CLBP-related disability.Purpose: To examine associations between CLBP-related disability at 12-month follow-up and individual, psychosocial and physical factors at baseline, as well as treatment-related factors between baseline and 12-month follow-up among a Saudi population. Additionally, associations between pain intensity and general perceived efficacy (GPE) at 12 months were examined with the aforementioned factors.Design: A prospective cohort study.Participants: One hundred Saudi participants over 18 years with a history of LBP greater than 3 months' duration.Main Outcome Measurements: The primary outcome variable was CLBP-related disability measured by the Arabic Oswestry disability index. Secondary outcome measures were pain intensity over the prior week measured by the VAS and the participant's global perceptions of recovery (general perceived efficacy [GPE]) at 12 months.Methods: At baseline (n=115), participants completed questionnaires covering demographics, disability, pain intensity, back beliefs, fear avoidance, psychological distress, and physical activity. They performed standardized physical performance tests, including assessment of pain behaviors using a pain behavior scale. After 12 months, participants (n=100) completed questionnaires on disability, pain intensity, GPE and provided treatment-related information during the previous year. Predictors of disability, pain, and GPE were explored using univariate and multivariate regression analyses.Results: The prognostic model for moderate-severe CLBP-related disability at 12 months explained 53.0% of the variance. Higher pain intensity, higher fear-avoidance work, and older age predicted higher disability. Having no additional somatic symptoms predicted lower disability. Pain intensity at 12-month follow-up was explained by higher disability at baseline, while not being in paid employment appeared protective (25.7% of variance explained). As univariate associations were weak between predictor variables and GPE, multivariate analysis was not conducted.Conclusion: The study results supported the multifactorial nature of CLBP and reported an important prognostic model in the Saudi population. [ABSTRACT FROM AUTHOR]

Background: The present study evaluated the influence of psychological factors (anxiety, depression, fear avoidance, and self‐efficacy) in predicting patient adherence to their personalised post‐intervention treatment maintenance plan for the interval between discharge from an out‐patient treatment and follow‐up at 3–6 months. Methods: Participants included 61 chronic pain patients aged 31–72 years (M = 54.28, SD = 10.32) who had completed a pain management program between 2014 and 2016 at a rehabilitation centre. Participants completed measures of the psychological factors at pre‐intervention and at the completion of the program; and a measure of treatment maintenance adherence at 3–6 months post‐intervention to measure compliance with the post‐discharge treatment plan. The psychological factors at both timepoints were included in regression models to determine whether pre‐ or post‐intervention scores predict adherence, and whether these effects are dependent on how much these psychological factors change during the intervention phase. Results: Hierarchical regression analyses showed that 28% variance in post‐intervention adherence to post‐intervention treatment maintenance plans was accounted for by the predictors. Fear avoidance and depressive symptoms (both at post‐intervention) made significant unique contributions to prediction. Moderation analyses showed that individuals with initially low levels of anxiety, whose symptoms worsened during the intervention phase, were more likely to adhere to the post‐discharge treatment plan. Conclusions: This pattern of findings shows relevance for psychological factors in treatment adherence. Nevertheless, questions remain about the nature of their influence on adherence, and clinical and research implications are discussed in this light. [ABSTRACT FROM AUTHOR]

Objective: To evaluate feasibility and acceptability of a sub-threshold exercise program with minimal in-person visits to treat youth with persistent sport-related concussion, and explore efficacy for improving concussive symptoms, health-related quality of life, and fear-avoidance. Study design: We conducted a pilot randomized controlled trial comparing a 6 week sub-threshold exercise program requiring only two in-person visits to active control (stretching) for 12–18 year old youth with persistent sport-related concussion. We measured moderate-to-vigorous physical activity pre- and post-intervention using accelerometry, and increased goals weekly via phone contact. We examined feasibility and acceptability using qualitative interviews. We used exponential regression to model differences in trajectory of concussive symptoms by experimental group, and linear regression to model differences in trajectory of health-related quality of life and fear-avoidance of pain by experimental group. Results: Thirty-two subjects randomized, 30 completed the study (n = 11 control, n = 19 intervention), 57 % female. Youth and parents reported enjoying participating in the study and appreciated the structure and support, as well as the minimal in-person visits. Exponential regression modeling indicated that concussive symptoms declined more rapidly in intervention youth than control (p = 0.02). Health-related quality of life and fear-avoidance of pain improved over time, but were not significantly different by group. Conclusions: This study indicates feasibility and potential benefit of a 6 week subthreshold exercise program with minimal in-person visits for youth with persistent concussion. Potential factors that may play a role in improvement such as fear-avoidance deserve further study. [ABSTRACT FROM AUTHOR]